This application is for Home Performance with ENERGY STAR Trade Allies to submit upon completion of attic insulation installation for qualified customers. Purchase and installation must occur between January 1, 2013 and December 31, 2013 and funds are available on a first-come, firstserved basis. Please return the signed, completed application and copy of sales invoice showing that the instant discount was applied. Applications must be postmarked within 30 days of installation. Missing information will delay processing. Questions? Contact us at 800.762.7077. SECTION 1: CUSTOMER INFORMATION Where did the customer hear about this program? q Community Association/Agency q Utility q Friend/Neighbor q Contractor q Other First Name: Last Name: RESIDENTIAL REWARDS PROGRAM ATTIC INSULATION APPLICATION Phone Number: Email: Installation Address: City: State: Electric Utility: (at installation address) Electric Utility Account Number: WI Zip: Gas Utility: (at installation address) Gas Utility Account Number: Fuel Used for Home Heating: (Only homes heated with natural gas or electricity are eligibile) q Natural Gas q Propane q Oil q Electric q Other: Fuel Used for Water Heating: q Natural Gas q Propane q Oil q Electric q Other: Property Type: (Only dwellings with 1-3 units are eligible for these Cash-Back Rewards) q Single Family q Multifamily 2-3 Units q Other: Is this an: (New construction is not eligible for these rewards) q Existing Home q New Construction Estimated Age of Home: SECTION 2: TRADE ALLY INFORMATION (Must be a Focus on Energy Home Performance with ENERGY STAR Trade Ally) Central Air Conditioning in the Home: Company/Business Name: Email: Phone: Address: City: State: Zip: SECTION 3: TRADE ALLY SIGNATURE (Please read the complete reward application and sign) I, the undersigned, agree that the stated energy efficient measure(s) was (were) installed at the project site address listed above as part of the Focus on Energy program offering and that I am authorized to sign this application. I have read and agree to the terms and conditions within this application. To the best of my knowledge, the statements made on this application are complete, true, and correct, and I have submitted the appropriate supporting documentation showing the instant discount was applied to the sales invoice. q Itemized contractor invoice is attached Trade Ally Signature: Print Name: Date: SECTION 4: CUSTOMER SIGNATURE (Please read the complete reward application and sign) I, the undersigned, agree that the stated energy efficient measure(s) was (were) installed at the project site address listed above as part of the Focus on Energy program offering and that I am authorized to sign this application. I have read and agree to the terms and conditions within this application. To the best of my knowledge, the statements made on this application are complete, true and correct, and I have submitted the appropriate supporting documentation to receive a Cash-Back Reward. I understand the Cash-Back Reward was applied as an instant discount on my sales invoice and I authorize the Cash-Back Reward from Focus on Energy to be paid directly to the Trade Ally noted in Section 2. Applicant Signature: Print Name: Date: FORM SUBMITTAL - Return signed, completed reward application and copy of sales invoice to: Mail: Focus on Energy Rewards, 222 W. Washington Ave., Suite 470, Madison, WI 53703-2793 Email: homerewards@focusonenergy.com Fax: 888.627.0938 Questions: 800.762.7077 ResRewards_AtticInsulationApp_0113 1 of 7
ATTIC INSULATION Attic Insulation Cash-Back Rewards - $300, not to exceed 75% of total installed cost: n Area improved must be a minimum of 400 square feet. n Existing construction only. n Air sealing must be done prior to installation of insulation. n Open Cavity: o Maximum existing level of R-11 of insulation prior to installation. o Minimum level of R-38 of insulation post installation. n Closed Cavity: o No insulation can be in the cavities prior to installation. o Cavities must be completely dense packed. n Must be installed by a Focus on Energy Home Performance with ENERGY STAR Trade Ally. For a list of participating Trade Allies visit finditwithfocus.com. n Installer must follow the Attic Air Sealing and Insulation Program Material and Installation Guidelines. This document can be found at focusonenergy.com/tradeally/home-performance/default.aspx. n A combustion safety test following Building Performance Institute (BPI) procedure or a combustion spillage test must be performed prior to, and after, attic air sealing and insulation work. Submittal of a Combustion Equipment Notification signed by the Trade Ally and customer is required. This document can be found at the end of this application or at focusonenergy.com/tradeally/home-performance/default.aspx. n At least 50 percent of the heating energy for the home must come from electricity purchased from a participating electric utility or from natural gas purchased from a participating natural gas utility. n May only receive one Attic Insulation Cash-Back Reward per address per year. n May not claim Cash-Back Reward under Home Performance with ENERGY STAR for same work. n Trade Allies should not enter job into EnergyMeasure HOME. Attic Area: (ft 2 ) R-Value Before Installation: Installation Date: Air Sealing and Insulation Cost: Insulation Material Used Insulation Manufacturer: Type of Insulation: R-Value: (per inch) R-Value After Installation: Quantity: (bag count) Air Sealing Work Completed Chimney/Mechanical Penetrations: q All q Partial ne q N/A Open Cavities: q All q Partial ne q N/A Knee Wall Transitions: q All q Partial ne q N/A Bath Fans: q All q Partial ne q N/A Electrical/Plumbing Penetrations: q All q Partial ne q N/A Dropped Soffits: q All q Partial ne q N/A Other Attic Level Transitions: q All q Partial ne q N/A Recessed Lights: q All q Partial ne q N/A Attic Access: q All q Partial ne q N/A Top Plates: q All q Partial ne q N/A TOTAL CASH-BACK REWARD: 75% of installed cost up to $300, whichever is less $ OFFER AVAILABILITY n Focus on Energy rewards are available to Wisconsin residential customers of participating utilities. Call 800.762.7077 or visit focusonenergy.com to verify eligibility. n Offer is valid for material purchased and installed between January 1, 2013 and December 31, 2013. n Rewards may not exceed the total purchase price of the installation. The only costs eligible for rewards are: Materials and External Labor. n Allow approximately 8-10 weeks for your completed application to be processed. Incomplete applications cannot be processed. Failure to complete the reward application in full and provide the required supporting documentation will either delay the payment process or result in your application being denied. Receipt of an application does not guarantee payment of a Cash-Back Reward. n The program is not responsible for items (i.e. reward applications, supporting documentation, reward checks) lost or damaged in the mail. n Only single family dwellings and multifamily dwellings with three or fewer units are eligible for the Cash-Back Rewards included in this reward application. Cash-Back Rewards may be available for other customer or property types. Please visit focusonenergy.com for other offerings and reward applications. n Focus on Energy will only pay one Cash-Back Reward for each installation. Cash-Back Rewards paid on this application cannot be claimed on another Focus on Energy application. n All installations are subject to verification inspection by the program to ensure the material is properly installed and operating. Participants must allow, if requested, the program or a program representative reasonable access to their home to verify the installation. 2 of 7
PROGRAM QUALIFICATIONS You are only eligible to participate in the Residential Rewards Attic Insulation Program if you are: n A current residential customer of a participating utility in Wisconsin at the time of installation; or n A landlord (who is not the utility account holder) who paid for the installation in the residence of a current residential customer of a participating utility in Wisconsin at the time of installation; and n Installing in an existing residential dwelling. New construction does not qualify. Your installation is only eligible for a Cash-Back Reward if: n It meets all energy efficiency and program requirements as outlined in this application. n It is purchased new. Resale material or material that is leased, rebuilt, rented, received from insurance claims, received from a warranty, or won as a prize does not qualify. n Material is installed by a Focus on Energy Home Performance with ENERGY STAR Trade Ally. n Material is installed conforming to all applicable building, local, state and federal codes, standards, ordinances and regulations, and manufacturer specifications. n Material is installed prior to submittal of this application at the address listed on the application. n It is installed in a single family dwelling or a multifamily dwelling with three or fewer units. n It is installed in a property owned by the applicant, or the applicant has received permission from the property owner to install the material. If you do not own the property where this equipment is installed, as a residing tenant you are responsible for obtaining the owner s permission to install the material for which you are applying for a Cash-Back Reward. Your submission of this application indicates that you have obtained this permission. n It is purchased and installed during the program offering period: January 1, 2013 through December 31, 2013. To be considered complete and eligible for Cash-Back Rewards, all applications must: n Be postmarked no later than 30 days after the installation date, or by January 31, 2014, whichever comes first. n Be signed by the purchaser (Customer, Landlord, or Applicant signing on behalf of the Customer). n Include Itemized Contractor Invoice(s) or Proof of Purchase Receipt(s) containing: o Total installed cost (itemized by each product installed) o Purchase date and installation date (if purchased and installed on separate dates) o Professional contractor s business/company name, address, and phone number o Instant Discount applied to invoice o Balance due of zero, paid in full stamp, or payment terms FOCUS ON ENERGY GENERAL TERMS AND CONDITIONS This is a Focus on Energy program application for use by eligible applicants ( Applicant ). Shaw Environmental and Infrastructure, Inc. is the Program Administrator for Focus on Energy ( Program Administrator ) and bound by contract to Statewide Energy Efficiency and Renewable Administration, Inc. ( SEERA ). Integrated Resource Solutions Group, LLC is the Program Implementer for Focus on Energy ( Program Implementer ) and is bound by contract to Program Administrator. The Program Administrator, Program Implementer, Focus on Energy and the Applicant may be individually referred to herein as a Party and collectively as the Parties. Section 1. Incentive Offer: This Application covers products purchased and installed between January 1, 2013 and December 31, 2013. Applications must be postmarked within 30 calendar days of installation and no later than January 31, 2014. Applicants should maintain a copy of this application for their personal records. Incomplete applications will be returned and will not be processed. This application must have complete information and be submitted with proof of purchase such as invoices that clearly itemize the product(s) and/or services(s) received. Purchase orders, proposals and quotes are not considered proof of purchase. Section 2. Marketing: The Applicant shall not use Program Administrator s or SEERA s corporate name, logo, identity, any affiliation, or any related logo including the Focus on Energy name, logo, or identity, for any marketing, advertising or solicitation without prior written consent of Focus on Energy. Such written consent may be withheld in Focus on Energy s sole discretion. When referencing Focus on Energy involvement with any project, the Applicant shall collaborate with Focus on Energy to prepare any press release and to plan for any news conference and agrees to provide Focus on Energy, for its written approval prior to publication, a written copy of any advertisements or promotional material regarding this program prior to publishing any such advertisements or promotional material. Focus on Energy reserves the right to publicize the Applicant s participation in the Focus on Energy program unless a written request is submitted to focusonenergy.marketing@shawgrp.com. Section 3. Program Discretion: Rewards are available on a first-come, first-served basis. This offer is subject to change or termination without notice at the discretion of Focus on Energy. Some Focus participating electric and/or natural gas providers have incentive programs outside of Focus on Energy. Customers of these providers might not qualify for incentives from both programs. These customers should check with their electric and/or natural gas provider to verify eligibility for dual incentives in order to comply with program rules. Focus on Energy excludes internal labor (i.e. non-contracted labor) for private companies or individuals when calculating total project costs. Applicants who are served by a participating electric provider but not a participating natural gas provider will only qualify for incentives for electric technologies. Applicants who are served by a participating natural gas provider but not a participating electric provider will only qualify for incentives for natural gas technologies. Applicants who have both a qualifying electric provider and a qualifying natural gas provider will qualify for incentives on both electric and natural gas technologies. Applicants who use Liquid Propane (LP) or other non-qualifying fuels will not qualify for incentives for any gas technologies. Focus on Energy reserves the right to change or discontinue this program at any time without notice. Focus on Energy also reserves the right to withhold incentive payment until identified problems with a project are resolved and to withhold or terminate an incentive payment due to any party s failure to follow any and all applicable terms and conditions, rules, or procedures. The acceptance of incentive applications and qualification of systems is determined solely by Focus on Energy and acceptance of this application does not guarantee payment of an incentive. In the event that SEERA terminates, for any cause, Program Administrator s contract with SEERA, which terminates Program Administrator s right to act as Program Administrator of the Focus on Energy Program, responsibility for this Application shall be transferred to the new Program Administrator. Section 4. Disclaimers, Representations, and Warranties: Focus on Energy, the Program Administrator, Program Implementer, and SEERA (collectively for this section Focus on Energy ) do not endorse any particular trade ally, manufacturer, product, system, or design by offering an incentive. Focus on Energy is not responsible for any tax liability imposed on the recipient as a result of the payment of incentives. Focus on Energy makes no representation or warranty, and assumes no liability with respect to the quality, safety, performance, or other aspect of any design, consulting, product, system, equipment, or appliance installed or received and expressly disclaims any such representations, warranties, and liability, including, but not limited to, any implied warranties of merchantability or fitness for a particular purpose. Focus on Energy does not guarantee that installation and operation of incentivized measures will result in reduced energy usage or in cost savings. Focus on Energy is not responsible for the proper disposal/recycling of any waste generated as a result of this project. Focus on Energy is not liable for any damages, including any incidental or consequential damages, arising out of the operation or malfunction of the products, equipment, or appliances, or the installation thereof. Section 5. Monitoring, Verification, Record Keeping, and Right to Inspect: Focus on Energy evaluates program efficacy by monitoring energy use/production prior to and after installation of your energy efficiency or renewable energy project. Focus on Energy, and its designated representatives, shall have the right to monitor energy use/ production prior to and after installation of the project or to perform an inspection of project records or the project itself to evaluate program efficacy for a period of two (2) years from the date of incentive payment. The Applicant s signature on this application provides Focus on Energy approval to obtain energy data directly from your electric and/or natural gas provider(s). The Applicant and its subcontractors shall maintain accurate records of the project work (e.g., installation records, invoices, and maintenance information) that is performed hereunder for a period of two (2) years from the date of incentive payment. 3 of 7
FOCUS ON ENERGY GENERAL TERMS AND CONDITIONS, CONTINUED Section 6. Indemnification: Applicants agree to protect, indemnify, defend and hold harmless Focus on Energy, Program Administrator, Program Implementer, SEERA, the State of Wisconsin and participating utilities, their respective affiliates, subsidiaries, parent companies, officers, directors, agents, and employees, against all losses, damages, expenses, fees, costs and liability arising from any program, design, consulting, product, system, equipment, or appliance. The Applicant agrees that such obligations under this section shall survive any expiration or termination of this Application and shall not be limited by any enumeration herein of required insurance coverage. To the maximum extent permitted by law, the Applicant agrees to limit Program Administrator and Program Implementer s liability to the Applicant for any reason to the total amount of the payments identified in this Agreement. This limitation shall apply regardless of the cause of action or legal theory pled or asserted. Applicant hereby expressly waives the right to specifically enforce this Application. Section 7. Misrepresentation: Making false statements on any Focus on Energy incentive application is punishable by law. Any person who knowingly files an application containing any materially false information or who purposely and misleadingly conceals information commits a fraudulent act that subjects such person to criminal and civil penalties. Any and all funds determined, in Focus on Energy s sole discretion, to have been acquired on the basis of fraudulent or misrepresented information must be fully returned to the Focus on Energy program. Should the Applicant or its representative apply for and receive duplicate payment, Focus on Energy reserves the right to recover payments made in excess of the entitled Reward. This section shall not limit other remedies that may be available for the filing of false or fraudulent applications. Section 8: Miscellaneous: (1). Governing Law. This Application shall be governed, construed and enforced in accordance with the internal laws of the State of Wisconsin, without regard to any law of conflicts that may direct the application of the laws of another jurisdiction. The Applicant irrevocably submits to the original jurisdiction of the state and federal courts sitting in Madison, Wisconsin with regard to any controversy in any way relating to the execution, delivery or performance of this Application that is not resolved by Arbitration. Suits, claims or actions founded upon such controversies shall be brought or filed exclusively in such courts and nowhere else. The exclusive venue for any dispute or controversy arising under this Agreement shall be the Dane County, Wisconsin Circuit Court or the Federal District Court for the Western District of Wisconsin. (2) Compliance with Applicable Laws. The Applicant shall at all times comply with and observe all federal and Wisconsin state laws and published circulars, local laws, ordinances, rules and regulations which are in effect during the period of this Application and which in any manner affect the performance of this Agreement. This Application shall be construed and enforced, in accordance with the laws of the State of Wisconsin and the laws of the United States. All references to statutes or regulations contained in this Application shall be construed to include successors thereto. (3). Assignment. Focus on Energy may assign, transfer or convey this Application or any of Focus on Energy s rights, obligations, interests or responsibilities hereunder, in whole or in part, without the consent of the Applicant. (4). Severability. If any provision of this Application is illegal, invalid, or unenforceable under present or future laws effective during the term of this Application, that provision shall be fully severable and this Application shall be construed and enforced as if the illegal, invalid, or unenforceable provision had never comprised a part of this Application. The remaining provisions of this Application shall remain in full force and effect and shall not be affected by the illegal, invalid, or unenforceable provision or by its severance. Furthermore, in lieu of such illegal, invalid, or unenforceable provision, this Application shall be reformed to include as a part of this Application a provision as similar in terms to the illegal, invalid, or unenforceable provision as may be possible and still be legal, valid, or enforceable. (5). Risk of Loss. Focus on Energy, Program Implementer and Program Administrator at no time assumes risk of loss for any personal property of the Applicant. (6). Waiver. Failure or delay on the part of either party to exercise any right, power, privilege or remedy hereunder shall not constitute a waiver thereof. A waiver of any default shall not operate as a waiver of any other default or of the same type of default on a future occasion. 4 of 7
This form must be submitted with a Residential Rewards Attic Insulation Application. Information provided on this form will provide the required proof of combustion safety test or combustion spillage test conducted at the installation address. Questions? Contact us at 800.762.7077. A combustion safety issue can be a potential life threatening or hazardous situation. This form verifies that a combustion safety test, following Building Performance Institute (BPI) Procedure, or a combustion spillage test were performed to identify potential back-drafting of heating and water heating appliances both before and after the attic air sealing and insulation measures were completed. The following conditions were identified: SECTION 1: CUSTOMER INFORMATION First Name: ATTIC AIR SEALING AND INSULATION COMBUSTION EQUIPMENT NOTIFICATION Last Name: Installation Address: City: State: Zip: SECTION 2: HEATING AND WATER HEATING EQUIPMENT IN THE HOME Equipment Type Equipment Venting Method Equipment Location q Furnace q Boiler q Water Heater q Direct q Power q Atmospheric q Induced Draft q Furnace q Boiler q Water Heater q Direct q Power q Atmospheric q Induced Draft SECTION 3: CONDITION OF VENT DUCT WORK OR CHIMNEY q Good q Fair q Poor q Good q Fair q Poor Please use a separate sheet for additional appliances. SECTION 4: TEST RESULT Pre-Test Result Post-Test Result test was performed N/A N/A There are no combustion appliances in the home or all of the appliances are direct or power vented. q Test was stopped/not performed N/A N/A Test was stopped due to appliance operation concerns. See Additional on page 3. q BPI Combustion Safety Test (see page 2) q Work Required Issue q Issue See page 2 for notes on issue result. q Combustion Spillage Test (see page 3) q Work Required Issue q Issue See page 3 for notes on issue result. SECTION 5: APPLICATION SIGNATURES (Please read the complete notification and sign) By signing below, I acknowledge that the conditions as described above exist in my home, I have been informed of the situation, and I agree to hold the installing Trade Ally harmless. The installing Trade Ally expressly disclaims any and all warranties or representations of any kind, whether oral, statutory, expressed, or implied, including without limitation warranties of suitability or fitness. This notice does not constitute an endorsement or warranty regarding the presence or absence of other real or potential health and safety hazards that may exist at the installation address or on the premises. Applicant Signature: Trade Ally Signature: Print Name: Date: Print Name: Date: FORM SUBMITTAL - Return signed, completed notice along with a copy of the reward application to: Mail: Focus on Energy Rewards, 222 W. Washington Ave., Suite 470, Madison, WI 53703-2793 Email: homerewards@focusonenergy.com Fax: 888.627.0938 Questions: 800.762.7077 ResRewards_CombustionEquipmentNotification_0113 5 of 7
SECTION 6: BPI COMBUSTION SAFETY TEST If performing a combustion safety test following BPI procedure, all of the procedure must be followed and acted on in accordance with the BPI action levels. Conditions before attic air sealing and insulation work: Carbon Result Monoxide (CO) Level Ambient: q Pass q Fail q N/A - See Oven/ q Pass q Fail Range: q N/A - See Combustion Zone (CAZ) Depressurization - Worst Case Spill Test Result Draft Pressure Result Combustion Zone (CAZ) Depressurization - Natural* Spill Test Result Draft Pressure Result Conditions after attic air sealing and insulation work: CO Level Result Ambient: q Pass q Fail Oven/ Range: q Pass q Fail Combustion Zone (CAZ) Depressurization - Worst Case Spill Test Result Draft Pressure Result q Pass q Fail Issue q Pass q Fail Issue Combustion Zone (CAZ) Depressurization - Natural* Spill Test Result Draft Pressure Result q Pass q Fail Issue q Pass q Fail Issue *Combustion safety test for natural conditions is only required if issue exists under worst case conditions. 6 of 7
SECTION 7: COMBUSTION SPILLAGE TEST Conditions before attic air sealing and insulation work: Nothing-- Passed at Initial Conditions Door to CAZ Actions needed in order for appliance to stop spillage: Kitchen Fan Fan One Fan Two Dryer Turned off HVAC Blower Window/ Added Make-up Air Result If equipment fails, it is recommended that the customer contact an HVAC contractor to correct the venting issue, add make-up air to CAZ, or confirm appliance operation. The installation of a CO detector and alarm in also recommended. Conditions after attic air sealing and insulation work: Nothing-- Passed at Initial Conditions Door to CAZ Actions needed in order for appliance to stop spillage: Kitchen Fan Fan One Fan Two Dryer Turned off HVAC Blower Window/ Added Make-up Air Result Issue Issue If equipment fails, it is recommended that the customer contact an HVAC contractor to correct the venting issue, add make-up air to CAZ, or confirm appliance operation. The installation of a CO detector and alarm in also recommended. ADDITIONAL NOTES 7 of 7